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indicate that at least 6000 persons had immediate access to medical and related services provided by the project. Occupancy at the two fixed camps varied during the seven month period:

Harney Lane-low of 75 families, high of 126 (June).

Vatthews Road-low of 42 families, high of 140 (September). Data regarding family size and length of stay in the fixed camps are available, and will be analyzed. Public health nurses have identified several groups of migrant families who did not live in the fixed camps, but who utilized the camp medical clinic services.

Estimates only are available for the migrant population in the areas served by the mobile medical clinic:

Acampo, 400-500 (includes 40 families in one private camp).
Linden, 1000-1200 (several private camps).
Terminous, 50–75.
Thornton, 150–200.

Vernalis, 500-550 (80 families in private camps). Continued effort will be made to obtain more reliable estimates of the migrant population during various times of the year.

In previous years, the migrant population in San Joaquin County has been estimated as 12,000-13,000. A large proportion of total migrants comes to this County during che harvest (May-June). Although medical services were initiated at the Harney Lane Camp in April

, the mobile clinic service did not start until July. Operation of the mobile clinic during the period April-June next year will allow provision of care for a greater number of migrants than received service this year.

VI. Costs.--All claims for payment for services and supplies have not yet been received, and project records have not yet been audited. However, current review of records indicates that all components of the project have remained well within the amounts budgeted. All services provided will be subjected to cost analysis when the projects are completed. VII. Problems Encountered.

A. The hospitalization component of the comprehensive project could not be implemented, because funds for this purpose were not available. Indie viduals in need of inpatient care were referred to San Joaquin General Hospital, resulting in loss of continuity of care.

B. Initiation of in-office care and utilization of laboratory resources were necessarily delayed until adequate financial support was assured in July.

C. Facilities at Harney Lane and Matthews Road Camps were less than ideal for clinic activities. A portion of available space was necessarily used for other camp activities (educational and social). Opening of the second unit at the Matthews Road Camp improved the space situation for the clinie at that location.

D. Attendance at the first few sessions of the mobile clinic was low, even though efforts to stimulate attendance were made prior to the clinic dates. Public Health Nurses and Health Aides devoted additional time to locating migrant families and providing information about available services, with the result that mobile clinic attendance increased during succeeding weeks.

E. Dental care was provided for a relatively small number of individuals. The project budgets included only token amounts for dental care, and referrals initially were limited to patients having dental emergencies. Late in the summer, permission was granted to use otherwise uncommitted funds for purchase of additional dental services. However, time did not permit development of a more comprehensive service before the fixed camps were

closed. VIII. Plans for 1968.--Physicians in San Joaquin County believe that the feasibility and desirability of providing comprehensive medical services for migrant families have been demonstrated. If adequate financial support can be obtained, services for 1968 will include:

1. Outpatient medical services at the fixed migrant camps, beginning in April, 1968. As the existing State OEO contracts terminate March 31, 1968, medical services can be provided at Harney Lane and Matthews Road camps only if funding is assured prior to that date.

2. Mobile medical clinic services to outlying areas in which migrant families will reside. Experience gained during the first five months of the current project will be utilized in determing the locations to be served. Consideration will be given to providing medical services for single male agricultural workers, if facilities are provided for housing these men next year. As the existing contracts for support of the mobile medical clinic terminates on June 30, 1968, provision of services during the summer and fall will be contingent upon receipt of assurance that this program will be funded during 1968-1969.

3. In-office medical, dental, laboratory, and radiological services. During a five month period, this project has demonstrated that migrant individuals have a need for medical services more comprehensive than can be provided in a camp clinic. The project has also demonstrated that, contrary to the beliefs of some, migrants will accept referral to private resources, if assisted in doing so.

4. Hospitalization in community hospitals in the areas in which migrants reside. Continuity of care can be achieved only if in-hospital care can be provided by the physicians who are providing outpatient care. Migrants are entitled to the same quality of care as are residents of the area, and such care

must include hospitalization. The present program is supported by three State and Federal contracts in the amount of $162,223. Experience gained during the past eight months indicates that this amount, plus approximately $10,000 additional for dental care (primarily for children), wouid allow provision of an adequate level of otpaticnt services during the period April 1, 1968-June 30, 1969. The addition of $50,000 for hospitalization would allow provision of truly comprehensive services.

The figures recorded in II-F above regarding hospitalization represent a minimum estimate of the need for inpatient care. As indicated in the comprehensive plan originally submitted in February, 1967 (QV), available information indicates that the migrant population in San Joaquin County will represent a group at risk of approximately 3000 person-years, would require approximately 2100 days of inpatient care, if such care were readily available, and would cost approximately $100,000. Previous estimates of the cost of in-hospital medical care and the source of the local share of the cost of hospitalization are still valid.

Dr. GIANELLI. Now, just so you won't think that this is a one-man project, I would like to submit exhibits B and C. These are speeches delivered by the president of our county seat, Dr. John Morzumi, one delivered in Chandler, Ariz., and another in northern California.

Senator WILLIAMS. That is not in the material that you presented?

Dr. GIANELLI. I will submit them. I didn't want to confuse you with all of the papers. I thought perhaps you would think we were trying to run competition to the Government, but in both reports a prominent position is given to our agricultural program and I will leave these with the secretary.

(The material referred to previously follows:)

WESTERN CONFERENCE ON FUTURE DIRECTIONS AND DECISIONS IN MEDICAL

CARE

(Comments from the San Joaquin County Medical Society, John Morzumi, M.D.,

President) Public Law 89–749 has been the cause of a deep sense of urgency in the minds of the members of the San Joaquin County Medical Society. This feeling is as much borne out of what we don't know as what we do know and what our experience has been. I would like to take a few moments to outline what our experience has been in the few areas that are appropriate to the discussions of this conference.

REGIONAL HEALTH FACILITIES PLANNING

Our Medical Society became interested in the concept of regional health facilities planning in 1953. A local attempt had been made by our Hospital Council to organize a regional health facilities planning council and their grant application had been denied. It was during this period that the Medical Society recognized the need for regional planning and passed a resolution supporting the concept.

Upon a request from community leaders, the Medical Society loaned its staff and resources in an attempt to organize a regional health facilities planning council that would meet with the approval of the State Department of Public Health

and the U.S. Public Health Services. A six-county region was established and an
application was drawn up and submitted. This application was ultimately ap-
proved, resulting in the establishment of the North San Joaquin Valley Regional
Health Council. Our county society's executive secretary served as the initial
executive director during this organizational period and until an adequate staff
was secured.
Our involvement at the present time is as follows:

1. General support as a matter of policy.
2. Financial support.

3. Representation through individual physician members appointed to the
local county committees and to the governing board.
We are strongly committed to the principle of voluntary planning and would be
interested in seeing this type of program become more vital and virile under
any new structure set up to qualify for Public Law 89–749.

Last month our county medical society joined with our County Board of Supervisors and with the North San Joaquin Valley Regional Health Council in adopting a joint resolution which issued a general call to the community for interest and involvement in the establishment of a regional program that would qualify under Public Law 89–749.

HEALTH PROFESSIONS TRAINING COUNCIL The Medical Society, in cooperation with several other agencies, has long recognized the serious implications involved when there is an inadequate supply of para-medical personnel coupled with a rising demand for such services.

Because of this concern, the Medical Society organized, in April, 1966, the Health Professions Training Council in an attempt to evaluate and to promulgate ways to recruit and develop medical manpower to meet these needs. The Council is composed of representatives from education, hospitals, medicine, nursing, and employment. Membership in the Council is held by representatives of:

San Joaquin County Board of Supervisors.
San Joaquin County Hospital Council.
San Joaquin General Hospital,
Director of Nursing, San Joaquin General Hospital.
San Joaquin Delta College.
Division of Nursing, San Joaquin Delta College.
California State Department of Employment.
Stockton Unified School District.
District Nurses Association.
Visiting Nurses Association.
San Joaquin Local Health District.
Longterm Care Facilities Association.
San Joaquin Valley Regional Health Planning Council.
University of the Pacific.

San Joaquin Dental Society.
The purpose of the Council is to:

i. Obtain and synthesize data on the volume of jobs, their location, wage rates, personal and educational standards and relationships to job advancement and career opportunities.

2. Determine the need and supply of para-medical personnel and project this into the future.

3. Analyze the cost factors involved in school courses and facility clinical training under varying patterns of operation.

4. Explore the methods of teaching, length of training period and the effectiveness of various teaching aids.

5. Analyze the possibilities of career advancement training and design a system to implement such a program, The first meeting of the Council was held in October of 1966. Since that time the Council has had several study projects before it and has made some recommendations that have led to meaningful programs. The medical profession has been surveyed to ascertain whether or not there was a need for a training course for medical assistants. A refresher course for R.N.'s was stimulated at our local junior college. A recommendation has been made that hopefully will help lead to the establishment of a bacalaureate program for nurses at the University of the Pacific. Upon the Council's recommendation, a nurses aid training program using M.D.T.A. funds was established in cooperation with the State Department of Employment. A survey of the local dental profession resulted in the presentation of a course at

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San Joaquin Delta Junior College for employed dental assistants and a two-year course for dental assistants will be started at San Joaquin Delta Junior College in 1968. In general however, the Council has felt inadequate because of lack of staff and financing although all the member agencies cooperated. The Council must rely on the staff of the county medical society.

The Council has made a proposal to the Community Health Services of the United States Public Health Service, Region IX for a grant to carry on their work. The initial proposal was made in January, 1967.

Discussions with persons in Community Health Services has led us to believe that although the need for financial support of this type of program is apparent, our particular grant proposal will probably not be accepted at this time. An alternate suggestion was made to us which we would readily accept. This proposal was to study the potentiality of placing at the Medical Society's and at the Council's disposal an employee of the Public Health Department to help carry out staff functions. This person would assist in carrying out staff functions of the Health Professions Training Council and work in other areas of similar interest.

AGRICULTURAL WORKERS The San Joaquin County Medical Society could not possibly exist in an area such as ours without being aware of and concerned for the health needs of agricultural workers. Each year we can expect approximately 12,000 migrant agricultural workers through our county. For the past ten years, through one form or another, the Medical Society has been attempting to establish a pilot program in order to not only render care to these people but more importantly, to develop means by which their needs can be analyzed and programs developed in order to meet these needs.

It was not however, until April 1 of this year that the Medical Society was able to successfully implement a program. This program receives funds from four sources:

1. Office of Economic Opportunity, $76,322.
2. United States Public Health Services, $60,901.
3. State of California, $25,000.

4. Regional Demonstration Center, Migrant Education, $18,680. These amounts are for a grant period of April 1, 1967 to March 31, 1968. The proposal is a two year proposal. The proposal for the second year is similar to the first with the exception that initial money that was initially budgeted and not funded is being requested. This additional money amounts to approximately $100,000.00 and is for private hospitalization for persons to be covered. This particular proposal is through the Medical Society's Foundation for Medical Care and in cooperation with the San Joaquin Local Health District, the San Joaquin Pharmaceutical Association, and the San Joaquin County Board of Supervisors. The project objectives are:

A. To provide comprehensive family health services for migrant agricultural workers and families through provision of:

(1) Medical outpatient clinic services at Harney Lane and Mathews Road migrant camps.

(2) Mobile outpatient clinic services in areas in which migrant agricultural workers reside, and which are far removed from other sources of medical care available to such workers and families: Acampo, Linden, Terminous, Thornton, Vernalis.

(3) Continuity of care between outpatient clinic sessions, by establishing fee-for-service arrangements with general practitioners in each of the areas in which agricultural workers reside.

(4) Hospitalization in community hospitals when inpatient care is indicated.

(5) Public health nursing, environmental sanitation, and health aide services in all areas in which migrant agricultural workers reside or work. B. Coordinate family health services provided by project staff with health services available through all other resources in the community.

C. Obtain and evaluate precise information regarding health problems of migrant agricultural workers and families:

(1) Extent and types or unmet medical needs.

(2) Volume of medical and paramedical services required to meet identified needs.

(3) Manner in which needed services can best be provided.
(4) Cost of providing the indicated services.
(5) Problems related to coordination of community health service

resources.

Accomplishment of this objective will provide the medical, sociological, and fiscal information needed in planning to meet the health needs of migrant agricultural workers on a continuing basis. Project needs and background

San Joaquin County lies in the mid-portion of the central valley of California, near the junction of the San Joaquin and Sacramento Rivers. The economy of the County is predominantly agricultural: of the 1409 square miles, approximately 90 percent is devoted to agricultural activities; the value of agricultural commodities produced annually exceeds $224,000,000.

As of July 1, 1966, the estimated population of the County was 278,800. A little over one-third of the population resides in the City of Stockton, which is located near the center of the County; an additional 40,000-45,000 individuals live in suburban areas adjacent to Stockton. The remainder of the population resides in five smaller cities and in the unincorporated areas.

Population estimates and 1960 Federal Census reports indicate that: During the past five years, the population of San Joaquin County has increased at the rate of approximately 1.9% per year; the population includes a bigh proportion of young persons and an increasing proportion of older individuals; the proportion of Negroes, other non-whites and Mexican Americans is high, particularly in the City of Stockton; a high proportion of the total population is in the lower socioeconomic group; average educational level is low; and approximately twenty per cent of all housing units are substandard.

During 1965–1966, unemployment rates ranged from a low of 4.3% in September to a high of 9.6% in February; throughout the year, seasonal agricultural workers constitute a large portion of the unemployed group). Employment figures listed include domestic residents, domestic migrants, and some 4580 Mexican Nationals, and 574 other foreign contract laborers. Method of procedure

Medical and related health services will be provided by the San Joaquin County Medical Society, through the Foundation for Medical Care and in cooperation with the San Joaquin Local Health District and other agencies as follows:

A. Fixed outpatient medical clinic services are established at:

(1) Harney Lane Migrant Camp-estimated maximum capacity: 480 persons. Clinic services are provided five nights per week, Monday through Friday, 7-10:00 p.m.

(2) Mathews Road Migrant Camp--estimated maximum capacity 800 persons. Clinic services will be provided five nights per week, Monday through Friday, 7-10:00 P.M.

At both camp sites, services will be provided for an estimated 3000 persons who will be residents of the camps during the period April 1October 31, 1967, and to such other migrant workers and families living nearby who can be encouraged to utilize the health services offered. Services described below will be provided without any type of eligibility determination. Efforts will be made, however, to identify individuals who may be eligible for service under one or more of the several public medical care programs (e.g. Medi-Cal, CCS, Federal Medicare),

and to assist such individuals in obtaining needed care. B. Mobile medical clinic services will be provided for migrant workers and families living in or near Acampo, Linden, Terminous, Thornton, and Vernalis, once weekly at each location, on a regular schedule, during the period April 1, 1967- March 31, 1968. Clinic hours will be arranged to meet the needs of clients in each location.

C. Outpatient medical services will be provided in the offices of private physicians located nearest to each clinic site, to provide service at times other than regularly scheduled for clinics. Insofar as possible, private care will be provided by the same physicians who ve served at clinic sessions, in order to provide continuity of care.

D. Clinical laboratory and radiological services will be provided through existing arrangements with service facilities, as established by the Foundation for Medical Care.

E. Inpatient care will be provided in seven open-staff community hospitals located in Stockton, Lodi, Manteca, and Tracy. Specific referral procedures will be developed.

F. Public health nursing, environmental sanitation, and health aide services provided in the project will be coordinated with related services

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